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      Systemic thrombolysis and endovascular thrombectomy in severe acute ischemic stroke after dabigatran reversal with idarucizumab

      case-report

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          Key Clinical Message

          Patients presenting with an acute ischemic stroke despite dabigatran therapy (last intake <24 h or unknown) should be evaluated for reversal by idarucizumab, making them eligible for safe and effective intravenous thrombolysis. It has been shown to be feasible, well‐tolerated, and easy to manage in an emergency room or stroke unit.

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          Idarucizumab: The Antidote for Reversal of Dabigatran.

          John W Eikelboom, Daniel Quinlan, Joanne van Ryn … (2015)
          Article 0 comments Cited 35 times – based on 0 reviews     Review now
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            Antagonizing dabigatran by idarucizumab in cases of ischemic stroke or intracranial hemorrhage in Germany - A national case collection.

            Pawel Kermer, Christoph Eschenfelder, Hans-Christoph Diener … (2017)
            Background Idarucizumab is a monoclonal antibody fragment with high affinity for dabigatran that reverses its anticoagulant effects within minutes. It may exhibit the potential for patients under dabigatran therapy suffering ischemic stroke to regain eligibility for thrombolysis with rt-PA and may inhibit lesion growth in patients with intracerebral hemorrhage on dabigatran. Aims To provide insights into the clinical use of idarucizumab in patients under effective dabigatran anticoagulation presenting with signs of ischemic stroke or intracranial hemorrhage. Methods Retrospective data collected from German neurological/neurosurgical departments administering idarucizumab following product launch from January to August 2016 were used. Results Thirty-one patients presenting with signs of stroke received idarucizumab in 22 stroke centers. Nineteen patients treated with dabigatran presented with ischemic stroke and 12 patients suffered from intracranial bleeding. In patients receiving rt-PA thrombolysis following idarucizumab, 79% benefitted from i.v. thrombolysis with a median improvement of five points in NIHSS. No bleeding complications occurred. Hematoma growth was observed in 2 out of 12 patients with intracranial hemorrhage. The outcome was favorable with a median NIHSS improvement of 5.5 points and mRS 0-3 in 67%. Overall, mortality was low with 6.5% (one patient in each group). Conclusion Administration of rt-PA after reversing dabigatran activity with idarucizumab in case of ischemic stroke is feasible, easy to manage, effective, and appears to be safe. In dabigatran-associated intracranial hemorrhage, idarucizumab has the potential to prevent hematoma growth and improve outcome. Idarucizumab represents a new therapeutic option for patients under dabigatran treatment presenting with ischemic stroke or intracranial hemorrhage.
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              Management of acute stroke in patients taking novel oral anticoagulants

              Graeme Hankey, Bo Norrving, Werner Hacke … (2014)
              Each year, 1·0–2·0% of individuals with atrial fibrillation and 0·1–0·2% of those with venous thromboembolism who are receiving one of the novel oral anticoagulants (dabigatran, rivaroxaban, or apixaban) can be expected to experience an acute ischemic stroke. Additionally, 0·2–0·5% of individuals with atrial fibrillation who are receiving one of the novel oral anticoagulants can be expected to experience an intracranial hemorrhage. This opinion piece addresses the current literature and offers practical approaches to the management of patients receiving novel oral anticoagulants who present with an ischemic or hemorrhagic stroke. Specifically, we discuss the role of thrombolysis in anticoagulated patients with acute ischemic stroke and factors to consider concerning restarting anticoagulation after acute ischemic and hemorrhagic stroke.
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                Author and article information

                Contributors
                Cedric Hermans: cedric.hermans@uclouvain.be
                Journal
                Journal ID (nlm-ta): Clin Case Rep
                Journal ID (iso-abbrev): Clin Case Rep
                Journal ID (doi): 10.1002/(ISSN)2050-0904
                Journal ID (publisher-id): CCR3
                Title: Clinical Case Reports
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Electronic): 2050-0904
                Publication date (Electronic): 27 February 2018
                Publication date Collection: April 2018
                Volume: 6
                Issue: 4 ( doiID: 10.1002/ccr3.2018.6.issue-4 )
                Pages: 698-701
                Affiliations
                [ 1 ] Hemostasis and Thrombosis Unit Division of Adult Hematology Cliniques Universitaires Saint‐Luc Brussels 1200 Belgium
                [ 2 ] Division of Radiology Cliniques Universitaires Saint‐Luc Brussels 1200 Belgium
                [ 3 ] Division of Neurology Cliniques Universitaires Saint‐Luc Brussels 1200 Belgium
                [ 4 ] Division of Cardiology Cliniques Universitaires Saint‐Luc Brussels 1200 Belgium
                Author notes
                [*] [* ] Correspondence

                Cedric Hermans, Division of Adult Haematology, Haemostasis and Thrombosis Unit, Haemophilia Clinic, St‐Luc University Hospital, Avenue Hippocrate 10, B‐1200 Brussels, Belgium. Tel: +32‐02‐764‐17‐85; Fax: +32‐2‐764‐89‐59; E‐mail: cedric.hermans@ 123456uclouvain.be

                Author information
                http://orcid.org/0000-0003-3299-2385
                Article
                Publisher ID: CCR31446
                DOI: 10.1002/ccr3.1446
                PMC ID: 5889252
                PubMed ID: 29636943
                SO-VID: 91269eb8-f8e6-4608-941a-1517c3317a21
                Copyright © © 2018 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 02 December 2017
                Date revision received : 19 January 2018
                Date accepted : 04 February 2018
                Page count
                Figures: 2, Tables: 1, Pages: 4, Words: 2033
                Categories
                Subject: Case Report
                Subject: Case Reports
                Custom metadata
                source-schema-version-number 2.0
                component-id ccr31446
                cover-date April 2018
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:version=5.3.4 mode:remove_FC converted:06.04.2018

                Keywords: acute ischemic stroke,dabigatran etexilate,idarucizumab,thrombectomy,thrombolysis
                Data availability:
                Keywords: acute ischemic stroke, dabigatran etexilate, idarucizumab, thrombectomy, thrombolysis

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